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IntroductionLow socioeconomic status (SES) is associated with poor mental health and cognitive function. Individual-level SES and area-level SES (ASES) may affect mental health and cognitive function through lifestyle. We aimed to quantify the associations of ASES with mental health and cognitive function and examine the mediating role of lifestyle behaviours independent of individual-level SES in a Norwegian population.MethodsIn this cross-sectional study, we included 7211 participants (54% women) from the seventh survey of the Tromsø Study (2015–2016) (Tromsø7). The exposure variable ASES was created by aggregating individual-level SES variables (education, income, housing ownership) from Statistics Norway at the geographical subdivision level. Tromsø7 data were used as mediators (smoking, snuff, alcohol, physical activity, diet) and outcomes (cognitive function, anxiety, depression, insomnia). Mediation and mediated moderation analysis were performed with age as a moderator, stratified by sex.ResultsHigher ASES was associated with better cognitive function and fewer depression and insomnia symptoms, independent of individual-level SES. These associations were mediated by smoking and physical activity. Alcohol was a mediator for depression and cognitive function in women. Age was a significant moderator of the association between ASES and global cognitive function in women. The largest total indirect effect of ASES was found for depression, with the joint effect of the mediators accounting for 36% of the total effect.ConclusionsPeople living in areas with lower ASES are at higher risk of poor mental health, such as depression and insomnia, and have lower cognitive function possibly due to unhealthy lifestyle (smoking, alcohol and physical inactivity).

ObjectiveAssociations between occupational physical activity (OPA) and mortality risks are inconclusive. We aimed to examine associations between (1) OPA separately and (2) jointly with leisure time physical activity (LTPA), and risk of all-cause, cardiovascular disease (CVD) and cancer mortality, over four decades with updated exposure and covariates every 6–8 years.MethodsAdults aged 20–65 years from the Tromsø Study surveys Tromsø3-Tromsø7 (1986–2016) were included. We categorised OPA as low (sedentary), moderate (walking work), high (walking+lifting work) or very high (heavy manual labour) and LTPA as inactive, moderate and vigorous. We used Cox/Fine and Gray regressions to examine associations, adjusted for age, body mass index, smoking, education, diet, alcohol and LTPA (aim 1 only).ResultsOf 29 605 participants with 44 140 total observations, 4131 (14.0%) died, 1057 (25.6%) from CVD and 1660 (40.4%) from cancer, during follow-up (median: 29.1 years, 25th–75th: 16.5.1–35.3). In men, compared with low OPA, high OPA was associated with lower all-cause (HR 0.83, 95% CI 0.74 to 0.92) and CVD (subdistributed HR (SHR) 0.68, 95% CI 0.54 to 0.84) but not cancer mortality (SHR 0.99, 95% CI 0.84 to 1.19), while no association was observed for moderate or very high OPA. In joint analyses using inactive LTPA and low OPA as reference, vigorous LTPA was associated with lower all-cause mortality combined with low (HR 0.75, 95% CI 0.64 to 0.89), high (HR 0.67, 95% CI 0.54 to 0.82) and very high OPA (HR 0.74, 95% CI 0.58 to 0.94), but not with moderate OPA. In women, there were no associations between OPA, or combined OPA and LTPA, with mortality.ConclusionHigh OPA, but not moderate and very high OPA, was associated with lower all-cause and CVD mortality risk in men but not in women. Vigorous LTPA was associated with lower mortality risk in men with low, high and very high OPA, but not moderate OPA.

The heart normally has a regular rhythm. However, in an increasing number of adults worldwide, the rhythm is irregular, which is known as arrhythmia. Atrial fibrillation, or AF, is the most common type of arrhythmia. We know that the risk of AF may be related to lifestyle. In this project, we investigated how much the risk of AF in the population could have been reduced by improvements in smoking habits, physical activity level, alcohol intake, body mass index (BMI), and blood pressure. We found that the risk could have been reduced by 41% in women and 14% in men if everyone quit smoking, was sufficiently physically active, limited their alcohol intake to two units per week, lowered their BMI to 25 kg/m2, and lowered their blood pressure to 130/80 mm Hg. Reducing BMI was the most effective intervention to prevent AF.Graphical Abstract

There is an immediate need to optimize cardiovascular (CV) risk management and primary prevention of childhood obesity to timely and more effectively combat the health hazard and socioeconomic burden of CV disease from childhood development to adulthood manifestation. Optimizing screening programs and risk management strategies for obesity-related CV risk in childhood has high potential to change disease trajectories into adulthood. Building on a holistic view on the aetiology of childhood obesity, this document reviews current concepts in primary prevention and risk management strategies by lifestyle interventions. As an additional objective, this scientific statement addresses the high potential for reversibility of CV risk in childhood and comments on the use of modern surrogate markers beyond monitoring weight and body composition. This scientific statement also highlights the clinical importance of quantifying CV risk trajectories and discusses the remaining research gaps and challenges to better promote childhood health in a population-based approach. Finally, this document provides an overview on the lessons to be learned from the presented evidence and identifies key barriers to be targeted by researchers, clinicians, and policymakers to put into practice more effective primary prevention strategies for childhood obesity early in life to combat the burden of CV disease later in life.

Graphical AbstractFrom 1994 to 2016 atrial fibrillation incidence rates decreased in women and increased following a reverse U-shape in men. Reduction in systolic and diastolic blood pressure in women and increase in body mass index in men had the largest contribution to the trends. These findings provide further knowledge in the field of sex-specific risk stratification and personalised prevention of atrial fibrillation in clinical practice.

Myocardial infarction (MI) is associated with an increased risk of venous thromboembolism (VTE). Obesity is a recognized risk factor for both MI and VTE. Whether obesity further increases the risk of VTE in MI patients is scarcely investigated. To study the joint effect of MI and obesity on the risk of VTE. Study participants (n= 29 410) were recruited from three surveys of the Tromsø Study (conducted in 1994–1995, 2001, and 2007–2008) and followed up through 2014. All incident MI and VTE cases during follow‐up were recorded. Cox regression models with MI as a time‐dependent variable were used to estimate hazard ratios (HRs) of VTE (adjusted for age and sex) by combinations of MI exposure and obesity status. Joint effects were assessed by calculating relative excess risk and attributable proportion (AP) due to interaction. During a median of 19.6 years of follow‐up, 2090 study participants experienced an MI and 784 experienced a VTE. Among those with MI, 55 developed a subsequent VTE, yielding an overall incidence rate (IR) of VTE of 5.3 per 1000 person‐years (95% confidence interval [CI]: 4.1–6.9). In the combined exposure group (MI+/Obesity+), the IR was 11.3 per 1000 person‐years, and the adjusted HR indicated a 3‐fold increased risk of VTE (HR 3.16, 95% CI: 1.99–4.99) compared to the reference group (MI−/Obesity−). The corresponding AP was 0.46 (95% CI: 0.17–0.74). The combination of MI and obesity yielded a supra‐additive effect on VTE risk of which 46% of the VTE events were attributed to the interaction.

Myocardial infarction (MI) is associated with an increased risk of venous thromboembolism (VTE). Obesity is a recognized risk factor for both MI and VTE. Whether obesity further increases the risk of VTE in MI patients is scarcely investigated.

Supplemental Digital Content is available in the text.Growing evidence suggests a consistent association between atrial fibrillation (AF) and cognitive impairment and dementia that is independent of clinical stroke. This report from the AF-SCREEN International Collaboration summarizes the evidence linking AF to cognitive impairment and dementia. It provides guidance on the investigation and management of dementia in patients with AF on the basis of best available evidence. The document also addresses suspected pathophysiologic mechanisms and identifies knowledge gaps for future research. Whereas AF and dementia share numerous risk factors, the association appears to be independent of these variables. Nevertheless, the evidence remains inconclusive regarding a direct causal effect. Several pathophysiologic mechanisms have been proposed, some of which are potentially amenable to early intervention, including cerebral microinfarction, AF-related cerebral hypoperfusion, inflammation, microhemorrhage, brain atrophy, and systemic atherosclerotic vascular disease. The mitigating role of oral anticoagulation in specific subgroups (eg, low stroke risk, short duration or silent AF, after successful AF ablation, or atrial cardiopathy) and the effect of rhythm versus rate control strategies remain unknown. Likewise, screening for AF (in cognitively normal or cognitively impaired patients) and screening for cognitive impairment in patients with AF are debated. The pathophysiology of dementia and therapeutic strategies to reduce cognitive impairment warrant further investigation in individuals with AF. Cognition should be evaluated in future AF studies and integrated with patient-specific outcome priorities and patient preferences. Further large-scale prospective studies and randomized trials are needed to establish whether AF is a risk factor for cognitive impairment, to investigate strategies to prevent dementia, and to determine whether screening for unknown AF followed by targeted therapy might prevent or reduce cognitive impairment and dementia.

The heart failure epidemic is growing and its prevention, in order to reduce associated hospital readmission rates and its clinical and economic burden, is a key issue in modern cardiovascular medicine. The present consensus document aims to provide practical evidence-based information to support the implementation of effective preventive measures. After reviewing the most common risk factors, an overview of the population attributable risks in different continents is presented, to identify potentially effective opportunities for prevention and to inform preventive strategies. Finally, potential interventions that have been proposed and have been shown to be effective in preventing HF are listed.

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Background Tobacco use is the single largest preventable risk factor for premature death of non-communicable diseases and the second leading cause of cardiovascular disease. In response to the harmful effects of tobacco smoking, the use of electronic cigarettes (e-cigarettes) has emerged and gained significant popularity over the past 15 years. E-cigarettes are promoted as safe alternatives for traditional tobacco smoking and are often suggested as a way to reduce or quit smoking. However, evidence suggests they are not harmless.Discussion The rapid evolution of the e-cigarette market has outpaced the legislator’s regulatory capacity, leading to mixed regulations. The increasing use of e-cigarettes in adolescents and young individuals is of concern. While the long-term direct cardiovascular effects of e-cigarettes remain largely unknown, the existing evidence suggests that the e-cigarette should not be regarded as a cardiovascular safe product. The contribution of e-cigarette use to reducing conventional cigarette use and smoking cessation is complex, and the impact of e-cigarette use on long-term cessation lacks sufficient evidence.Conclusion This position paper describes the evidence regarding the prevalence of e-cigarette smoking, uptake of e-cigarettes in the young, related legislations, cardiovascular effects of e-cigarettes and the impact of e-cigarettes on smoking cessation. Knowledge gaps in the field are also highlighted. The recommendations from the population science and public health section of the European Association of Preventive Cardiology are presented.

Supplemental Digital Content is available in the text.Cardiac thromboembolism attributed to atrial fibrillation (AF) is responsible for up to one-third of ischemic strokes. Stroke may be the first manifestation of previously undetected AF. Given the efficacy of oral anticoagulants in preventing AF-related ischemic strokes, strategies of searching for AF after a stroke using ECG monitoring followed by oral anticoagulation (OAC) treatment have been proposed to prevent recurrent cardioembolic strokes. This white paper by experts from the AF-SCREEN International Collaboration summarizes existing evidence and knowledge gaps on searching for AF after a stroke by using ECG monitoring. New AF can be detected by routine plus intensive ECG monitoring in approximately one-quarter of patients with ischemic stroke. It may be causal, a bystander, or neurogenically induced by the stroke. AF after a stroke is a risk factor for thromboembolism and a strong marker for atrial myopathy. After acute ischemic stroke, patients should undergo 72 hours of electrocardiographic monitoring to detect AF. The diagnosis requires an ECG of sufficient quality for confirmation by a health professional with ECG rhythm expertise. AF detection rate is a function of monitoring duration and quality of analysis, AF episode definition, interval from stroke to monitoring commencement, and patient characteristics including old age, certain ECG alterations, and stroke type. Markers of atrial myopathy (eg, imaging, atrial ectopy, natriuretic peptides) may increase AF yield from monitoring and could be used to guide patient selection for more intensive/prolonged poststroke ECG monitoring. Atrial myopathy without detected AF is not currently sufficient to initiate OAC. The concept of embolic stroke of unknown source is not proven to identify patients who have had a stroke benefitting from empiric OAC treatment. However, some embolic stroke of unknown source subgroups (eg, advanced age, atrial enlargement) might benefit more from non–vitamin K-dependent OAC therapy than aspirin. Fulfilling embolic stroke of unknown source criteria is an indication neither for empiric non–vitamin K-dependent OAC treatment nor for withholding prolonged ECG monitoring for AF. Clinically diagnosed AF after a stroke or a transient ischemic attack is associated with significantly increased risk of recurrent stroke or systemic embolism, in particular, with additional stroke risk factors, and requires OAC rather than antiplatelet therapy. The minimum subclinical AF duration required on ECG monitoring poststroke/transient ischemic attack to recommend OAC therapy is debated.

Background Primary prevention guidelines promote the use of risk assessment tools to estimate total cardiovascular risk. We aimed to study trends in cardiovascular risk and contribution of single risk factors, using the newly developed NORRISK 2 risk score, which estimates 10-year risk of fatal and non-fatal cardiovascular events.Design Prospective population-based study.Methods We included women and men aged 45–74 years attending the sixth and seventh survey of the Tromsø Study (Tromsø 6, 2007–2008, n= 7284 and Tromsø 7, 2015–2016, n= 14,858) to study secular trends in NORRISK 2 score. To study longitudinal trends, we followed participants born 1941–1962 attending both surveys (n= 4534). We calculated NORRISK 2 score and used linear regression models to study the relative contribution (%R2) of each single risk factor to the total score.Results Mean NORRISK 2 score decreased and distribution in risk categories moved from higher to lower risk in both sexes and all age-groups between the first and second surveys (p< 0.001). In birth cohorts, when age was set to baseline in NORRISK 2 calculations, risk score decreased during follow-up. Main contributors to NORRISK 2 were systolic blood pressure, smoking and total cholesterol, with some sex, age and birth cohort differences.Conclusion We found significant favourable secular and longitudinal trends in total cardiovascular risk and single risk factors during the last decade. Change in systolic blood pressure, smoking and cholesterol were the main contributors to risk score change; however, the impact of single risk factors on the total score differed by sex, age and birth cohort.

Aims This study examined the association of leisure time physical activity, occupational physical activity, and resting heart rate with all-cause and cardiovascular disease mortality in Sami and non-Sami populations.Study design This was a longitudinal, observational population-based study.Methods The Finnmark 3 study cohort was examined in 1987–1988 and followed for all-cause and cardiovascular disease mortality for 26 years. The cohort included 17,697 men and women with a mean age of 47.2 years at baseline. Leisure time physical activity and occupational physical activity were assessed with a validated questionnaire at baseline, whereas cause of death was obtained from the Norwegian Cause of Death Registry.Results A total of 1983 women and 3147 men died during follow-up. Leisure time physical activity was linearly and inversely associated with all-cause mortality, but not coronary heart disease mortality. Compared to inactive subjects, all-cause mortality was significantly reduced by 16% in the active leisure time physical activity group (hazard ratio 0.84; 95% confidence interval 0.76–0.92). Both for all-cause and cardiovascular disease mortality, we observed a U-shaped relationship with occupational physical activity, as participants in the walking and lifting group had significantly lower mortality than both the mostly sedentary and the heavy manual labour group (p< 0.05). An increase in resting heart rate by one beat per minute was associated with a 1.1% increase in all-cause mortality (hazard ratio 1.011; 95% confidence interval 1.009–1.013). The associations were similar in Sami and non-Sami subjects.Conclusion In this population-based study, leisure time physical activity was inversely associated with all-cause mortality, whereas resting heart rate was positively associated with all-cause and cardiovascular disease mortality. There was a U-shaped association between occupational physical activity and cardiovascular disease and all-cause mortality.

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Although commonly associated with cardiovascular disease or other medical conditions, atrial fibrillation may also occur in individuals without any known underlying conditions. This manifestation of atrial fibrillation has been linked to extensive and long-term exercise, as prolonged endurance exercise has shown to increase prevalence and risk of atrial fibrillation. In contrast, more modest physical activity is associated with a decreased risk of atrial fibrillation, and current research indicates a J-shaped association between atrial fibrillation and the broad range of physical activity and exercise. This has led to the hypothesis that the mechanisms underlying an increased risk of atrial fibrillation with intensive exercise are different from those underlying a reduced risk with moderate physical activity, possibly linked to distinctive characteristics of the population under study. High volumes of exercise over many years performed by lean, healthy endurance trained athletes may lead to cardiac (patho)physiological alterations involving the autonomic nervous system and remodelling of the heart. The mechanisms underlying a reduced risk of atrial fibrillation with light and moderate physical activity may involve a distinctive pathway, as physical activity can potentially reduce the risk of atrial fibrillation through favourable effects on cardiovascular risk factors.

Background Unrecognized myocardial infarction (MI) is a frequent and intriguing entity associated with a similar risk of death as recognized MI. Previous studies have not fully addressed whether the poor prognosis is explained by traditional cardiovascular risk factors. We investigated whether electrocardiographically detected unrecognized MI was independently associated with cardiovascular events and death and whether it improved prediction for future MI in a general population.Design Prospective cohort study.Methods We studied 5686 women and men without clinically recognized MI at baseline in 2007–2008. We assessed the risk of future MI, stroke and all-cause mortality in persons with unrecognized MI compared with persons with no MI during 31,051 person-years of follow-up.Results In the unadjusted analyses, unrecognized MI was associated with increased risk of future recognized MI (hazard ratio 1.84, 95% confidence interval (CI) 1.15–2.96) and all-cause mortality (hazard ratio 1.78, 95% CI 1.21–2.61), but not stroke (hazard ratio 1.09, 95% CI 0.56–2.17). The associations did not remain significant after adjustment for traditional risk factors (hazard ratio 1.25, 95% CI 0.76–2.06 and hazard ratio 1.38, 95% CI 0.93–2.05) for MI and all-cause mortality respectively. Unrecognized MI did not improve risk prediction for future recognized MI using the Framingham Risk Score (p= 0.96) or the European Systematic COronary Risk Evaluation (p= 0.65). There was no significant sex interaction regarding any of the endpoints.Conclusion Electrocardiographic unrecognized MI was not significantly associated with future risk of MI, stroke or all-cause mortality in the general population after adjustment for the traditional cardiovascular risk factors, and it did not improve prediction of future MI.

Background Resting heart rate is an established risk factor for cardiovascular disease, but long-term individual resting heart rate trajectories and their effect on cardiovascular disease morbidity and mortality have not yet been described.Methods This large population-based longitudinal study included 14,208 men and women aged 20 years or older, not pregnant and not using blood pressure medications, who attended at least two of the three Tromsø Study surveys conducted between 1986–2001. Resting heart rate was measured using an automated Dinamap device. Participants were followed up from 2001 to 2012 with respect to myocardial infarction, atrial fibrillation, ischaemic stroke, cardiovascular disease death and total death. The Proc Traj statistical procedure was used to identify resting heart rate trajectories.Results Five common long-term resting heart rate trajectories were identified: low, moderate, decreasing, increasing and elevated. In men, an elevated resting heart rate trajectory was independently associated with an increased risk of myocardial infarction when low resting heart rate trajectory was used as a reference (hazard ratio 1.83, 95% confidence interval 1.11–3.02). Risk of total death in men was lowest in the low resting heart rate trajectory group and highest in the increasing and elevated resting heart rate trajectory groups. In women, the association between resting heart rate trajectories and myocardial infarction was similar to that in men, but it was not significant.Conclusions Among the five long-term resting heart rate trajectories we identified, increasing and elevated trajectories were associated with an increased risk of myocardial infarction and total death in men. Our results suggest that changes in long-term individual resting heart rate in the general population may provide additional prognostic information.

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IMPORTANCE: It is not clear to what extent the higher incidence of coronary heart disease (CHD) in men vs women is explained by differences in risk factor levels because few studies have presented adjusted risk estimates for sex. Moreover, the increase in risk of CHD in postmenopausal women, possibly hormone related, may eventually eliminate the sex contrast in risk, but age-specific risk estimates are scarce. OBJECTIVE: To quantify the difference in risk of incident myocardial infarction (MI) between men and women. DESIGN, SETTING AND PARTICIPANTS: Population-based prospective study from Tromsø, Norway, comprising 33 997 individuals (51% women). Median follow-up time during ages 35 to 102 years was 17.6 years. Incidence rates (IRs) and incidence rate ratios (IRRs, relative risk) of MI were calculated in Poisson regression analysis of person-years at risk. The data analysis was performed in November 2015. EXPOSURES: Sex, age, birth cohort, serum lipid levels, blood pressure, lifestyle factors, diabetes. MAIN OUTCOMES AND MEASURES: Incident MI. RESULTS: A total of 2793 individuals (886 women) received a diagnosis of MI during follow-up in the period 1979 through 2012. The IR increased with age in both sexes, with lower rates for women until age 95 years. Adjusted for age and birth cohort, the overall IRR for men vs women was 2.72 (95% CI, 2.50-2.96). Adjustment for high-density lipoprotein cholesterol and total cholesterol levels had the strongest impact on the risk estimate for sex, followed by diastolic blood pressure and smoking. However, the sex difference remained substantial even after adjustment for these factors (IRR, 2.07; 95% CI, 1.89-2.26). Men had higher risk throughout life, but the IRRs decreased with age (3.64 [95% CI, 2.85-4.65], 2.00 [95% CI, 1.76-2.28], and 1.66 [95% CI, 1.42-1.95] for age groups 35-54, 55-74, and 75-94 years, respectively). Adjustment for systolic blood pressure, diabetes, body mass index, and physical activity had no notable impact. CONCLUSIONS AND RELEVANCE: The observed sex contrast in risk of MI cannot be explained by differences in established CHD risk factors. The gender gap persisted throughout life but declined with age as a result of a more pronounced flattening of risk level changes in middle-aged men. The minor changes in IRs when moving from premenopausal to postmenopausal age in women make it unlikely that changes in female hormone levels influence the risk of MI.

Las declaraciones de conflictos de intereses de los expertos participantes en el desarrollo de esta guía están disponibles en la página webde la ESC: www.escardio.org/guidelines

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Background/Aims:Estimated glomerular filtration rate (eGFR) is used extensively in epidemiological research. Validations of eGFR have demonstrated acceptable performance, but the dependence of creatinine and cystatin C on non-GFR factors could confound associations with disease. Few studies have investigated this issue in direct comparison with measured GFR (mGFR). We compared the associations between eGFR and mGFR and retinal vasculopathy, a marker of systemic microvasculopathy. Methods:Iohexol clearance and retinal photography were examined in the Renal Iohexol Clearance Survey in Tromsø 6, which consists of a representative sample of middle-aged persons from the general population. A total of 1,553 persons without self-reported kidney disease, cardiovascular disease or diabetes were investigated. Three eGFR equations based on creatinine and/or cystatin C from the Chronic Kidney Disease Epidemiology Collaboration were studied. Differences between eGFR and mGFR were analyzed with seemingly unrelated regression methods. Results:mGFR in the lowest quartile was associated with an increased multivariable-adjusted odds ratio of retinopathy (OR 1.86, 95% CI 1.16-2.97), but not with retinal artery or vein diameters. eGFR based on cystatin C (eGFRcys) was consistently biased relative to mGFR in its associations with retinal vessel diameters across different models. eGFR based on creatinine (eGFRcrea) and eGFR based on both creatinine and cystatin C were also biased in several of these models (p < 0.05). For retinopathy, the differences between the 3 eGFR and mGFR measurements were not statistically significant. Conclusions:Low mGFR is associated with retinopathy in the general population. eGFR based on creatinine and/or cystatin C are not valid substitutes for mGFR in studies of the relationship between the retina and kidney function in healthy persons.

Cardiovascular disease (CVD) is a leading cause of death and disability and living in areas with low socio-economic status (SES) is associated with increased risk of CVD. Lifestyle factors such as smoking, physical inactivity, an unhealthy diet and harmful alcohol use are main risk factors that contribute to other modifiable risk factors, such as hypertension, raised blood cholesterol, obesity, and diabetes. The potential impact of area-level socio-economic status (ASES) on metabolic CVD risk factors via lifestyle behaviors independent of individual SES has not been investigated previously.

Background:Atrial fibrillation (AF) is a common cardiac arrhythmia which increases morbidity and mortality. Identification of risk factors is therefore important. We examined the impact of palpitations and cardiovascular risk factors in prediction of AF (all types) and lone AF in a large population-based cohort.Design:We carried out a prospective population-based cohort study.Methods:A total of 22,815 participants from a population survey in 1994–1995 were followed-up for a mean of 11.1 years. Mean age at baseline was 46 years. Measurements of height, weight, blood pressure, heart rate, total cholesterol and high-density lipoprotein (HDL)-cholesterol, and information on palpitations, diabetes, angina, myocardial infarction, and antihypertensive treatment were obtained at baseline. The outcome measure was first-ever AF, documented on an electrocardiogram. Cox proportional hazards regression model was used to estimate hazard ratios (HRs) for AF.Results:Palpitations were associated with increased risk of AF in both women (HR 1.62, 95% confidence interval [CI] 1.29–2.02) and men (HR 1.91, 95% CI 1.54–2.35). For hypertension the HR for AF was 1.98 (1.46-2.69) in women and 1.40 (1.13-1.74) in men. The HR for 1 SD increase in body mass index (BMI) was 1.16 (1.06–1.27) in women and 1.47 (1.32–1.63) in men. Body height and BMI were associated with increased risk for lone AF in men.Conclusion:Palpitations, hypertension and BMI were predictive of future atrial fibrillation in both sexes.

IMPORTANCE Identification of structural heart disease in asymptomatic individuals could allow early disease-modifying treatment. OBJECTIVE To examine whether echocardiographic screening in the general population improves long-term survival or reduces the risk of cardiovascular disease. DESIGN, SETTING, AND PARTICIPANTS We studied 6861 middle-aged participants from the population-based Tromsø Study in Norway. INTERVENTION Participants were randomly allocated to an echocardiographic screening group (n = 3272) or a control group (n = 3589). MAIN OUTCOMES AND MEASURES Using the as-treated approach, the data were analyzed for mortality and incidence of fatal and nonfatal myocardial infarction and stroke. RESULTS During 15 follow-up years, 880 persons (26.9%) in the screening group and 989 persons (27.6%) in the control group died (hazard ratio, 0.97; 95% CI, 0.89-1.06). No significant differences between the groups were observed in the secondary outcome measures (sudden death, mortality from any heart disease, or incidence of fatal and nonfatal myocardial infarction and stroke). CONCLUSIONS AND RELEVANCE Echocardiographic screening for structural and valvular heart disease in the general population provided no benefit for mortality or for the risk of myocardial infarction or stroke.

Background: Although the mortality of coronary heart disease (CHD) has declined in Western countries during the last decades, studies have suggested that the prevention and treatment of CHD may not have been as effective in women as in men. We examined gender- and age-specific trends in incidence, case fatality and the severity of first myocardial infarction (MI) in a large Norwegian population-based study.Design: Prospective population-based cohort study.Methods: A total of 31,323 participants enrolled between 1974 and 2001 were followed throughout 2004 for a total of 400,572 person-years. Suspected coronary events were adjudicated by a review of hospital records and death certificates. A total of 1669 events fulfilled standardized criteria of first-ever fatal or non-fatal MI.Results: In the age group 35–79 years, the age-adjusted incidence of MI declined significantly in men, whereas an increase was observed in women. For men and women ≥80 years the incidence rates remained unchanged. The severity of MI and the 28-day and 1-year case fatality rates declined significantly and similarly in men and women.Conclusion: Trends in MI incidence differed by sex and age; in the age group 35–79 years a marked decrease was observed among men but an increase was observed among women, while no change was observed among older patients. MI severity and case fatality were clearly reduced for both sexes. These data suggest that the burden of CHD is shifting from middle-aged men toward middle-aged women and elderly patients.

Carotid plaque and intima-media thickness (IMT) are recognized as risk factors for ischemic stroke, but their predictive value has been debated and varies between studies. The purpose of this longitudinal population-based study was to assess the risk of ischemic stroke associated with plaque area and IMT in the carotid artery.

Background: A seasonal pattern with higher winter morbidity and mortality has been reported for acute myocardial infarction (MI). The magnitude of the difference between peak and nadir season has been associated with latitude, but results are inconsistent. Studies of seasonal variation of MI in population-based cohorts, based on adjudicated MI cases, are few. We investigated the monthly and seasonal variation in first-ever nonfatal and fatal MI in the population of Tromsø in northern Norway, a region with a harsh climate and extreme seasonal variation in daylight exposure.Design: Prospective population-based cohort study.Methods: A total of 37 392 participants from the Tromsø Study enrolled between 1974 and 2001 were followed throughout 2004. Each incident case of MI was validated by the review of medical records and death certificates. MI incidence rates for months and seasons were analyzed for seasonal patterns with Poisson regression and the Cosinor procedure. All analyses were stratified by sex, age and smoking status.Results: A total of 1893 first-ever MIs were registered, of which 592 were fatal. There was an 11 % (95% confidence interval: 1.00–1.23, P = 0.04) increased risk of incident MI during winter (November-January) compared with nonwinter seasons, with no statistically significant interaction with sex, age, smoking or calendar year. Other seasonal modelling gave similar but not statistically significant results.Conclusion: We found a small increase in risk of incident MI during the darkest winter months. Populations living in sub-Arctic areas may be adapted to face climate exposure during winter through behavioural protection.

Ultrasound of carotid arteries provides measures of intima media thickness (IMT) and plaque, both widely used as surrogate measures of cardiovascular disease. Although IMT and plaques are highly intercorrelated, the relationship between carotid plaque and IMT and cardiovascular disease has been conflicting. In this prospective, population-based study, we measured carotid IMT, total plaque area, and plaque echogenicity as predictors for first-ever myocardial infarction (MI).

Abstract: Haemoglobin level declines with increasing age in cross sectional studies. Little is known about the longitudinal changes of haemoglobin. Because both high or low haemoglobin levels increase mortality and morbidity we examined how changes in lifestyle factors like body mass index (BMI) and smoking habits influence cohort changes in haemoglobin level. In all, 4159 men aged 20–49 years at baseline were examined in 1974 and 1994–1995 in a longitudinal, population-based study from the municipality of Tromsø, Northern Norway. Mean haemoglobin was 148 g/l. There was no difference in mean haemoglobin after 20 years in any strata of age. Mean BMI increased 2.1 kg/m2. The prevalence of smokers decreased 20.1 percentage points. In a multiple regression analysis increase in BMI was associated with increased haemoglobin change. Smoking cessation lowered mean haemoglobin 1.6 g/l compared to never smokers. Haemoglobin increased 0.8 g/l in smoking quitters whose BMI increased >2.5 kg/m2 compared to a decrease of 6.7 g/l in weight reducers. There was a positive dose–response relationship between changes in cigarettes smoked per day and change in haemoglobin among consistent smokers. In conclusion, in contrast to cross sectional studies, mean haemoglobin did not change during 20 years ageing of relatively young men. This could be explained by higher BMI and less smoking. The increase in BMI affected haemoglobin change to such an extent that the reduction in haemoglobin due to smoking cessation was counteracted. Prospective studies are needed to address the health implications.

BackgroundIn epidemiological studies, the electrocardiogram has often been interpreted by means of a categorical classification. Computerized recording offers the possibility of analysing electrocardiographic measurements as continuous variables.ObjectiveTo test the hypothesis that duration of QRS complex and T-wave inversion would be independent predictors of myocardial infarction.MethodsIn a population-based study, we prospectively investigated the risk of developing myocardial infarction according to duration of QRS complex and peak-to-peak T-wave amplitude measured from lead I of the 12-lead electrocardiogram by computerized electrocardiography. In total 6628 men aged 25–61 years who had not previously suffered a myocardial infarction were followed up for 3.9 years.ResultsEighty-two first myocardial infarctions (55 non-fatal and 24 fatal myocardial infarctions and three sudden deaths) were identified. The risk of myocardial infarction increased with duration of QRS complex and with decreasing T-wave amplitude. A proportional hazards model with adjustment for possible confounders yielded a relative risk of myocardial infarction of 3.74 (P for linear trend 0.015) for duration of QRS complex ≥ 120 ms compared with duration of QRS complex < 80 ms. The multivariate relative risk for T-wave amplitude ≥ 0.35 mV compared with T-wave amplitude < 0.20 mV was 0.55 (P for linear trend 0.036). When both duration of QRS complex and T-wave amplitude were included in the multivariate model, T-wave amplitude retained its predictive power, whereas duration of QRS complex became marginally no longer significant (P = 0.067).ConclusionsPeak-to-peak T-wave amplitude from lead I is an independent predictor of myocardial infarction in men who have not previously suffered a myocardial infarction. Greater duration of QRS complex clearly indicates a higher risk of myocardial infarction. However, when T-wave amplitude is included as a covariate, the predictive power of duration of QRS complex does not remain significant Single-lead electrocardiography is a feasible method for improving the assessment of the relative risk of myocardial infarction.

In a survey, 19222 males and females aged 12-64 answered a question about sudden changes of heart rate or rhythm during the preceding year. The prevalence of reported arrhythmia was 12.4% in males and 17.2% in females.Multiple logistic regression was performed with self-reported arrhythmia as the dependent variable and psychological, lifestyle, and coronary risk factors as independent variables. The highest odds ratio for reported arrhythmia concerned poor compared with excellent health status; 3.86 in males and 2.98 in females. The relative risk for reported arrhythmia according to frequency of physician consultations was 2.28 in males and 1.70 in females, and odds ratios in both sexes were significant for psychological problems and smoking.The findings suggest that attention should be paid to the psychological conditions and lifestyle of patients who report irregular heartbeats. Self-reported arrhythmia may be a minor problem from a clinical point of view, but we still do not know its prognostic implications. Further work is necessary to determine the predictive strength of selfreported arrhythmia for morbidity and mortality.

When the University of Tromsø in northern Norway was founded in 1968, the region suffered from at serious lack of physicians and the health system was not efficient. It was believed that the establishment of a medical school would improve this situation. Half of the places would be reserved for students from northern Norway, and the curriculum would be designed particularly to adapt to the needs of society. The curriculum today aims at obtaining early involvement with patients by using the integrated model for teaching, which means no separation between preclinical and clinical periods and close patient contact throughout the whole curriculum. There is full integration between basic sciences and clinical medicine according to the organ-system model. Emphasis is put on teaching the students a scientific approach involving elective studies and a thesis based on independent study. The expectations of the planners of the medical school have, in the main, been fulfilled. Of the physicians now practising in northern Norway, the proportion who received their education in Tromsø exceeds that of those educated at the other Norwegian medical schools. In addition, there are no serious vacancies in the primary health care service in the region.